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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608984
Report Date: 05/13/2025
Date Signed: 05/13/2025 12:02:35 PM

Document Has Been Signed on 05/13/2025 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:INFINITY ELDER CARE INCFACILITY NUMBER:
197608984
ADMINISTRATOR/
DIRECTOR:		DIVINIA C. CRUZFACILITY TYPE:
740
ADDRESS:9253 BALCOM AVETELEPHONE:
(818) 813-1736
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 2DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Raul Cruz, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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On 05/13/2025 at 09:25 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with Caregiver, Raul Cruz. LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 9:50 am.

Bedrooms: There is six (6) bedrooms. There is four (4) resident bedrooms and two (2) staff bedrooms. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the residents sharing the room. In between the bedrooms there are cabinets filled with extra linen. There is also a pantry on your left-hand side of the entrance of the facility that is filled with extra chemicals locked and inaccessible to the residents.

Bathrooms: There are three (3) bathrooms that were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 105 degrees Fahrenheit and 106. The showers have non-slip bathmats and grab bars.

Medications were kept in a locked in a large, white cabinet in the kitchen. All medications were properly labeled and inaccessible to residents. There is a complete first aid kit located in the same large, white cabinet in the kitchen.

Kitchen Area: LPA inspected the kitchen area. There are two (2) refrigerators which were clean and in good operation. Knives and sharp objects were kept stored and locked in a cabinet located in the middle of the kitchen island on your left-hand side inaccessible to the residents. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinet. There is one (1) fire extinguisher that is expired.

809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984
VISIT DATE: 05/13/2025
NARRATIVE
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Living/Dining Room Area: LPA observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 71 degrees Fahrenheit with a large television. The other side of the living room also has furniture and another television with the telephone line access.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one (1) gate that is unlocked leading to the outside area towards the street. There are also ramps provided for the residents. There are two (2) sheds that LPA was able to observe where there is extra storage. The washer and dryer are located outside.

The carbon monoxide and the smoke detector were tested, and they were operable. The facility does have a signal system.

Garage: The garage is attached to the facility there is an access door from the kitchen area. It is used for additional storage of food and resident property.

Administration: The Infection control was reviewed. It is in a binder with the daily plan activities, Liability Insurance which expires 08/01/2025. There is another binder that has the Mandated Reporter Information, Theft and Loss, Emergency Numbers and House Rules. The Covid 19 signs are against the wall on your right-hand side of the entrance of the facility, hygiene sanitation signs, Emergency and Disaster Plan, Rights Personal Rights, YES sign, Approved Hospice Sign and Resident Bill of Rights. The fire drill is expired. The last fire drill was April of 2024. There is no staff with current CPR-Cardio Pulmonary Resuscitation.

There is currently one (1) staff working and there is one (1) resident who has dementia.

An exit interview was conducted, several citations were issued, and a copy of this report was given to the Caregiver along with the appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/13/2025 12:02 PM - It Cannot Be Edited


Created By: Gina Saucedo On 05/13/2025 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on the record review, the licensee did not comply with the section cited above in three out of three persons did not have cpr certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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CPR is to be reviewed and conducted and copies of CPR certification is to be sent to LPA.
Type A
Section Cited
CCR
87212(b)(2)(A)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observations the licensee did not comply with the section cited above in one out of one fire extinguisher was expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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A new fire extinguisher is to be bought and a copy of the receipt is to be sent to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/13/2025 12:02 PM - It Cannot Be Edited


Created By: Gina Saucedo On 05/13/2025 at 11:02 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the licensee did not comply with the section cited above in a quarterly fire or/and earthquake drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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A copy of the fire/earthquake drill shall be sent to the LPA and a copy is to be kept in the facility binder.
Type B
Section Cited
CCR
87705(e)(6)(B)
Care of Persons with Dementia
(e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (6) For each incident of elopement, as defined in Section 87101, Definitions, the licensee shall report the incident to: (B) The licensing agency Officer of the Day, by telephone, e-mail, fax, or hand-delivery no later than the next working day following the incident. If reported by telephone, a written report shall also be submitted to the licensing agency as specified in Section 87211, Reporting Requirements. The report shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review the licensee did not comply with the section cited above in one out of one resident who died within the last annual review and was not reported to CCLD which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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An Unusual/Incident/Death report is to be sent to CCLD within 24 hours/and or seven days notifying CCLD of any death and/or resident injuries.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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